My Wife Was Denied a Surgeon Due to Insurance. How Can I Get Her Employer to Approve a Plan Change?

Urgent Request for Help: Insurance Plan Change Needed for My Wife’s Treatment

I’m reaching out for immediate assistance from HR professionals, insurance brokers, or anyone knowledgeable about employer-sponsored health plans.

My wife has recently been diagnosed with grade 3 ductal carcinoma in situ (DCIS) in her left breast, and her doctor marked her case as urgent. Her primary care physician referred her to a qualified surgeon in Colorado for the necessary procedure, but her appointment was denied because her current insurance plan, Cigna Local Plus, doesn’t cover that provider.

When she contacted Cigna for in-network options, they only offered her a list of Physician Assistants (PAs) and Nurse Practitioners (NPs). Unfortunately, neither PAs nor NPs are authorized to perform a lumpectomy or mastectomy on their own, yet this is all Cigna covers under her current plan.

She has spoken with her employer’s HR department, and they indicated that a significant life event might warrant a plan change. We need to switch her to Cigna’s Open Access Plus plan, which the surgeon does accept, but HR has yet to confirm if this change will be approved.

Here are my questions for HR and insurance experts:

What arguments can she present to HR to enhance her chances of getting this plan change approved?
Is a serious medical diagnosis like DCIS generally considered a “major life change” that qualifies for insurance exceptions?
Are there any legal protections or employer responsibilities that could facilitate this process?
Should her doctor submit a formal letter to HR? If so, what should this letter include?

We are anxious to resolve this matter quickly so she can receive the necessary treatment without further delays due to insurance issues. Your guidance and strategies would be immensely appreciated. Thank you!

One thought on “My Wife Was Denied a Surgeon Due to Insurance. How Can I Get Her Employer to Approve a Plan Change?”

I’m really sorry to hear about your wife’s diagnosis and the difficulties you’re facing with her insurance. It’s a challenging situation, but there are steps you can take to advocate for her. Here are some suggestions based on your questions:

1. How to Argue Her Case to HR

Present Documentation: Compile all relevant medical documents, including her diagnosis, referral, and the urgency as noted by her doctor. Having your wife’s primary care physician provide documentation of the urgency of the situation can add weight to your request.
Highlight the Urgency: Clearly articulate that the referral is marked urgent and the need for timely surgical intervention. Stress that waiting for a plan change could compromise her health.
Express Emotional and Financial Impact: Emphasize the emotional toll this situation has on your family and consider mentioning the potential for escalating medical costs if she cannot use the surgeon you have identified.

2. Serious Medical Diagnosis and Major Life Changes

Generally, serious medical conditions such as cancer may be considered a “major life event” that could allow for a special enrollment period or plan change. It’s crucial to review the specific plan terms and talk to HR about their criteria for life events. Citing her condition as a serious health concern during your discussions could be persuasive.

3. Legal Protections and Employer Obligations

Under the Affordable Care Act (ACA), certain changes in health status or family circumstances may allow individuals to make changes to their insurance plans. Additionally, some employers have a legal obligation to accommodate employees with serious health conditions under the Americans with Disabilities Act (ADA). It might be useful to research if there are any state-specific laws in your area that provide additional protections.

4. Involve the Doctor

Yes, having her doctor write a formal letter to HR can be very beneficial. The letter should include:
A summary of her diagnosis and the urgency of the required surgery.
A statement of the doctor’s medical recommendation for her to see a specific surgeon, and the need for timely intervention.
Details regarding why the current insurance plan does not provide the necessary coverage (e.g., lack of covered in-network specialists capable of performing the required procedure).

Additional Strategies

Follow Up Regularly: Continue to follow up with HR politely but persistently. Ask for regular updates on the status of your case.
Explore External Resources: Consider reaching out to a medical social worker, patient advocate, or an attorney who specializes in health care law for additional support and guidance.
Utilize Any Additional Resources: Check if your employer has an Employee Assistance Program (EAP) that may offer resources or mediation support in navigating these types of issues.

Make sure to keep all communications documented. I hope this situation is resolved quickly and that your wife gets the care she needs. Best wishes to both of you during this difficult time.

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